Form MAP10 "Waiver Services Physician's Recommendation" - Kentucky

What Is Form MAP10?

This is a legal form that was released by the Kentucky Department of Medicaid Services - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2015;
  • The latest edition provided by the Kentucky Department of Medicaid Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form MAP10 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Medicaid Services.

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Download Form MAP10 "Waiver Services Physician's Recommendation" - Kentucky

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Commonwealth of Kentucky
Map 10
Cabinet for Health and Family Services
(Rev 06/15)
Department for Medicaid Services
WAIVER SERVICES
PHYSICIAN’S RECOMMENDATION
PLEASE RETURN TO THE REQUESTOR LISTED BELOW.
_____________________________________________________________________________________________
(Requestor’s Name)
_____________________________________________________________________________________________
(Address)
________________________________________________ KY___________ _____________________________
(City)
(Zip)
(Phone)
PHYSICIAN’S RECOMMENDATION
I recommend Waiver services for:
___________________________________________________
_______________________________________
(Member)
(Medicaid Member ID #)
_____________________________________________________________________________________________
(Address)
____________________________________________________ KY___________ _________________________
(City)
(Zip)
(Phone)
DIAGNOSIS (ES):
_____________________________________________________________________________________________
Recommended Waiver Program:
HCBW (APRN, PA or Physician signature)
ABI Waiver – Services to adults with a primary diagnosis of an acquired brain injury (18 yrs and older) with a potential for
rehabilitation and retraining (Physician signature)
ABI Long Term Care Waiver – Services to adults (18 yrs and older) with a primary diagnosis of an acquired brain injury
who has reached a plateau in their rehabilitation level and require maintenance services. (Physician signature)
SCL Waiver (SCL IDP or Physician signature)
Michelle P. Waiver – Non-residential Services to children and adults with intellectual or developmental disabilities.
(APRN, IDP, PA or Physician signature)
I certify that if Waiver services were not available, institutional placement in a Nursing Facility (NF) or
Intermediate Care Facility for Individuals with an Intellectual Disability shall be appropriate for this member.
(Authorized Signature)
(NPI #)
_____________________________________________________________________________________________________
(Address)
________________________________________________ KY
_______________ ______________________________
(City)
(Zip)
(Phone)
_______________________
(Date)
Commonwealth of Kentucky
Map 10
Cabinet for Health and Family Services
(Rev 06/15)
Department for Medicaid Services
WAIVER SERVICES
PHYSICIAN’S RECOMMENDATION
PLEASE RETURN TO THE REQUESTOR LISTED BELOW.
_____________________________________________________________________________________________
(Requestor’s Name)
_____________________________________________________________________________________________
(Address)
________________________________________________ KY___________ _____________________________
(City)
(Zip)
(Phone)
PHYSICIAN’S RECOMMENDATION
I recommend Waiver services for:
___________________________________________________
_______________________________________
(Member)
(Medicaid Member ID #)
_____________________________________________________________________________________________
(Address)
____________________________________________________ KY___________ _________________________
(City)
(Zip)
(Phone)
DIAGNOSIS (ES):
_____________________________________________________________________________________________
Recommended Waiver Program:
HCBW (APRN, PA or Physician signature)
ABI Waiver – Services to adults with a primary diagnosis of an acquired brain injury (18 yrs and older) with a potential for
rehabilitation and retraining (Physician signature)
ABI Long Term Care Waiver – Services to adults (18 yrs and older) with a primary diagnosis of an acquired brain injury
who has reached a plateau in their rehabilitation level and require maintenance services. (Physician signature)
SCL Waiver (SCL IDP or Physician signature)
Michelle P. Waiver – Non-residential Services to children and adults with intellectual or developmental disabilities.
(APRN, IDP, PA or Physician signature)
I certify that if Waiver services were not available, institutional placement in a Nursing Facility (NF) or
Intermediate Care Facility for Individuals with an Intellectual Disability shall be appropriate for this member.
(Authorized Signature)
(NPI #)
_____________________________________________________________________________________________________
(Address)
________________________________________________ KY
_______________ ______________________________
(City)
(Zip)
(Phone)
_______________________
(Date)